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Got cancer? You can probably get your IVF covered.

Today I had an inquiry from a student who is writing about access to infertility treatments and the role of insurance coverage to increase access to infertility treatments. Her inquiry got me thinking about one exception to the pretty universal denial of coverage for fertility treatments- the cancer diagnosis.

As many of you know from a previous post, I have advocated for fertility preservation for cancer patients and felt that the Oncofertility Consortium provides a lot of research-based cutting edge information and services through their partnership with IVF clinics. I knew that my own lab could be doing more for newly diagnosed cancer patients, particularly women who were facing the loss of their fertility as a consequence of chemotherapy, radiation therapy and/ or surgery to treat the cancer. Chemotherapy, in particular, has long been known to kill off ovarian follicles and advance menopause, often causing premature menopause. Men with cancer are more fortunate in that sperm production is an on-going process and often recovers after chemotherapy treatment if the testicles are spared. Furthermore, semen freezing and banking is a very effective “insurance” against sterility which has been available to men for decades.

One of the main barriers to early and effective fertility preservation treatments for cancer patients wasn’t just the absence of effective treatments but the dearth of effective counseling regarding fertility preservation options at the time of diagnosis. Traditionally, oncologists were slow to mention fertility preservation to newly diagnosed men and women as a recent study of oncologists’ counseling practices demonstrated. An added complication was that many physicians who were not fertility experts concluded that the return of menses after chemotherapy was evidence of fertility, so because menses often returned for women, oncologists didn’t think fertility preservation was necessary. We now know that the return of menses does not necessarily demonstrate fertility because menstruation alone is not evidence that healthy eggs are maturing in follicles. Professional societies like the American Society for Clinical Oncology have stepped up their education efforts with their membership and now advocate giving patients information about fertility treatment early enough that if the newly diagnosed patient wants to pursue fertility preservation before oncology treatments begin, there is enough time. Once oncology treatments begin, the damage may be done and fertility preservation is no longer effective.

In any case, the Oncofertility Consortium is an organized research based organization whose mission is both education about existing fertility preservation options and development of new fertility preservation options for patients. I worked through the lengthy lab application process and encouraged my doctors to become a physician partners with the Ocofertility consortium because the consortium promised that partner clinics would have access to the latest technical advances for freezing eggs, sperm, embryos and reproductive tissue (ovarian or testicular tissue). This research-based approach seemed immensely sensible to me because clinics were freezing sperm, eggs, embryos and tissues as needed in response to dire emergencies, often without any real expertise in best methods. My own lab had “inherited” a handful of frozen patient tissues from earlier emergency freezes which had little medical value because they were frozen based on “best practices” for freezing, not best practices for “ovarian transplant” which hadn’t yet been developed. So what could I tell those hopeful patients when they returned for the tissue? Uhm, yes it’s frozen but I don’t know if it is of any clinical use to you. The lab didn’t charge for those cases but we didn’t really provide a service either, as it turned out, just false hope. My solution to this problem was finding experts to partner with, namely the Oncofertility Consortium.

Another valuable service provided by the Oncofertility Consortium was information about how best to manage the insurance problem. Cancer is almost always covered under most medical insurance plans. Conversely, infertility is often NOT covered under most medical insurance plans. As it turns out, extension of fertility procedures like gamete or embryo freezing and banking are almost never covered for infertility patients, even if some other aspects of fertility diagnosis and treatment are covered by the plan. Except of course, if you lead with an oncology diagnosis. If the primary diagnosis is CANCER, then suddenly “No” becomes “Yes” and even freezing and annual banking costs were often covered for cancer patients.

Let me be clear. I think it is totally appropriate for insurance companies to cover fertility preservation treatments when someone has a cancer diagnosis. What is interesting and disturbing to me is why does it often take cancer to make fertility treatments considered worthy of coverage? Why is that? is there some greater right to reproduce if you have been through the flames of cancer treatment hell? Is it that cancer victims are seen as more vulnerable or more worthy of compassion compared to infertility patients who are often portrayed as selfish because otherwise why wouldn’t fertility patients just adopt? Is it because infertility treatments aren’t seen as really needed to preserve life, so they are considered optional and elective? By the same token, cancer patients don’t actually NEED fertility preservation to survive cancer, yet treatments as an adjunct to cancer treatments are often covered. Is it that insurance companies are more leery of the bad press that they would get if they denied coverage to a cancer patient and the patient went public with the denial? Kind of like Scrooge denying Tiny Tim’s father adequate wages to buy his crippled son a cane?

Ironically, I have heard the argument put forward that providing oncology patients with fertility preservation treatments is psychologically beneficial because it gives them something (future children) to look forward to and may give them more psychological strength to fight their disease and get well. From the study “Psychological aspects of fertility preservation in men and women affected by cancer and other life-threatening diseases“, it is put forward rather succinctly, quote ,”Considering the emotional impact of experiencing cancer, the patients’ knowledge that their fertility potential is secured might help to cope with and overcome this serious disease.” In essence, fertility preservation treatments such as IVF and embryo or gamete banking are considered just another tool in the tool kit to fight cancer. Interestingly, various studies have shown that patients suffering from infertility are prone to feelings of depression as deep as patients diagnosed with cancer. Infertility is another kind of disease that kills a person’s hope for the future. Why isn’t this recognized by insurance companies? Can’t fertility treatment likewise be considered a tool to fight depression and hopelessness created by a diagnosis of infertility?

One of my colleagues who had some high level interactions with insurance companies gave me some insights into what moves an insurance company. First, they need reassurance that they won’t have TOO MANY patients who will want and use a benefit they offer. Even though more people get cancer than suffer from infertility, most of the people who get cancer are frankly too old to be concerned about fertility preservation so insurance companies could be reassured that they wouldn’t have a tsunami of infertility claims coming in from cancer patients. In contrast, insurance companies worry that offering insurance coverage for regular infertility patients (one in six to eight couples) may be a negative financial model for them. But perhaps insurance companies need to be reminded about how IVF can be used to SAVE insurance companies money.

Ironically, there is another big avoidable financial drain on insurance companies, namely the cost of care provided to premature infants in neonatal intensive care units. Cases like Octomom leave people with the false impression that IVF must necessarily cause multiple gestation and premature birth. The widespread use of IVF has been correlated with an increase in the number of multiple births and the costs that come with the care of premature infants but that does not have to be the case. Since the number of embryos that are returned to the uterus is exactly controlled, theoretically, if elective single embryo transfer (eSET) were adopted on a widespread basis, singletons would be the rule from IVF. Rarely, identical twins might result if the transferred embryo splits once it is in the uterus.

Would patients agree to eSET if they could get their IVF covered? I think many patients would accept a slightly lower chance of conception each cycle if they could afford more cycles and could reduce their risk of pregnancy complications and loss by avoiding twins and higher order pregnancies. But currently, most IVF labs are twin factories because that’s what patients want. Why do patients want this? Well, doctors tell patients that their chances of pregnancy is higher when they transfer more embryos (true) but the fact that a patient’s risk of higher order multiples and risks associated with them are also increased, is not universally stressed by every RE. In my opinion, another reason patients want twins is because many patients can’t afford multiple IVF attempts and so feel compelled to get the whole family completed in one attempt. If insurance companies covered multiple IVF attempts, it would likely ease the financial pressure on patients to take extra chances and play embryo roulette.

Some questions you might ask your insurance company if they don’t offer insurance coverage for fertility treatments.

If I have cancer and I needed these services for fertility preservation, would some fertility procedures be covered? Which ones? Why or why not?

If I were to agree to a single embryo transfer so that my chance of a higher order pregnancy, premature birth and an extended stay in the NICU for my infant were practically nil, would you consider adding coverage for IVF procedures as a benefit on my plan? What would it take for you to offer infertility coverage?

Insurance companies respond to their covered clients, if enough of them make some noise.

4 Responses to this entry

I wish insurances would cover fertility preservation with a cancer diagnosis, but I just went through breast cancer 3 years ago at the age of 28. I work for a hospital that is self insured and could not get them to budge on their policy of no fertility coverage, despite my cancer diagnosis and having executive level folks speak up on my behalf. This needs to be a requirement for all insurances to cover preservation for young cancer patients as I now have fertility damage (definitely due to the chemotherapy I received. We forked over $13,000 with a cancer discount (not through insurance). My insurance covers nothing today, so we’ll have to fork over more for a transfer if we go that route. I’m a few months away from that being a reality. So while you say that “no” becomes “yes”, I have yet to meet another young cancer patient (and I’ve met many since my own diagnosis) to have such luck.

Dear K,
I am sorry you have had such a bad experience. Unfortunately, the existing insurance options don’t yet recognize the need to cover these services- you need to push hard on your own behalf. There are organizations that help fertility patients with fertility issues such as LIvestrong http://www.livestrong.org/we-can-help/fertility-services/ Fertile Hope is a program that offers financial assistance to patients who need fertility preservation. The application to apply can be found at this link http://www.fertilehope.org/financial-assistance/women_app_rev2012_FINAL.pdf If you want help with insurance claims- Fertility Within Reach is your best bet http://www.fertilitywithinreach.org/ The mission of Fertility Within Reach is to help patients get ACCESS to insurance coverage. FWR offers a lot of information on their website and also in person consultation by phone call. This older blog post also addresses this problem and provides resources http://fertilitylabinsider.com/2010/05/fertility-preservation-101/ I would reach out to a couple of these organizations –you might have more options than you think!! Don’t give up hope just yet. Wishing you much good luck going forward. Carole

Thank you Carole. We did use Fertile Hope / Livestrong for our fertility preservation. It was still $13000 with that (partly because we chose to go with a university institution and a doctor that specifically works with cancer patients), but the meds were provided at no cost (or it would have been higher). I will check Fertility Within Reach. I do plan to pursue coverage again with my insurance now that I have proven fertility issues post chemotherapy.

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Fertility Lab Insider

Lessons learned from over fifteen years of working inside fertility labs.